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Cardiopulmonary:

Encourage deep-breathing exercises.
Check for pain.

Rationale:

Encouraging deep-breathing exercises helps improve oxygenation and prevent complications such as atelectasis, especially since the client's oxygen saturation initially dropped but improved with deep breathing.

Checking for pain is essential as the client has been prescribed PRN morphine for pain management.

"Inform client to achieve two to four breaths per session when using an incentive spirometer" is not selected because while incentive spirometer use is encouraged, the prescribed plan instructs use every hour while awake rather than focusing on a specific number of breaths per session.

Gastrointestinal:

Promote intake of oral fluids.
Apply barrier ointment after bowel movements.

Rationale:

Promoting oral fluid intake helps prevent dehydration and supports bowel function, especially since the client reports multiple loose stools and nausea/vomiting.

Applying barrier ointment after bowel movements helps protect the skin from irritation and breakdown due to frequent loose stools.

"Encourage the client to increase fiber in their diet" is not selected because fiber intake is usually increased for constipation, whereas in this case, the client has diarrhea, and fiber could worsen symptoms.

After providing perineal care and donning sterile gloves, the nurse should first lubricate the catheter tip followed by insert the catheter until urine flows.

Rationale:

1. Lubricating the catheter tip ensures smooth insertion and minimizes discomfort or trauma to the urethra.
2. Inserting the catheter until urine flows confirms proper placement before advancing slightly more to ensure complete drainage.

The client is at risk for developing deep vein thrombosis (DVT) due to their immobility.

Rationale:

• Swelling and tenderness in the calf are key signs of DVT, which is a common complication of immobility after a stroke.

• Immobility leads to venous stasis, increasing the risk of clot formation.

The first client the nurse should assess is Client 3 (Pulmonary Edema) followed by Client 1 (Hip Fracture).

Rationale:

Client 3 (Pulmonary Edema) – Highest Priority:

1. 1. Pulmonary edema is a life-threatening condition that can impair oxygenation.
   2. The client has a history of congestive heart failure (CHF) and a chest x-ray confirming pulmonary edema.
   3. Immediate assessment is required to evaluate for respiratory distress, oxygenation status, and potential need for diuretics or oxygen therapy.

Client 1 (Hip Fracture) – Second Priority:

1. 1. The x-ray confirms a fractured femoral neck, which can cause severe pain, bleeding, and immobility.
   2. The nurse must assess for circulation, sensation, and movement (CSM) of the affected limb and manage pain.
   3. While this is urgent, it is not as immediately life-threatening as pulmonary edema.

Priority Order (Using ABCs & Maslow’s Hierarchy):

1. Client 3 – Pulmonary Edema (Airway/Breathing concern)
   2. Client 1 – Hip Fracture (Risk for bleeding, pain, mobility issues)
   3. Client 4 – Low Potassium (Risk for cardiac arrhythmias, needs electrolyte management)
   4. Client 6 – Poor Diabetes Control (HbA1c 9%, requires education & glucose monitoring)
   5. Client 5 – Malnutrition (Prealbumin 12 mg/dL, needs nutrition support for wound healing)
   6. Client 2 – Hyperlipidemia (Not an immediate concern, requires long-term management)

Client is difficult to arouse – This is concerning and may indicate opioid overdose or sedation due to the recent administration of morphine. The nurse should assess the client's level of consciousness closely and consider reversal of the opioid (naloxone) if the client's level of sedation is excessive.

Respiratory rate 10/min – This is below the normal respiratory rate (12–20 breaths/min) and could indicate respiratory depression, a common side effect of opioids like morphine. Close monitoring and possible intervention are required.

Pulse oximetry 88% on room air (95% to 100%) – The oxygen saturation is low, which could indicate hypoxemia. The nurse should administer supplemental oxygen and notify the provider.

Other Findings:

Pupils are 3 mm, equal, and reactive to light – This is a normal finding and not concerning for opioid overdose.

Blood pressure 99/46 mm Hg – This is slightly lower than normal but not critically low, considering the client's condition. Morphine can cause hypotension, especially in older adults or hypovolemic clients.

Heart rate 61/min – This is within a normal range for some postoperative patients, especially in a restful state.

The key pieces of information that indicate the client is at risk for falls include:

1. Admitted following a fall down approximately five steps – Indicates a recent fall history.
2. Client's partner reports client possibly hit their head and was a little disoriented for a minute or two – Suggests potential confusion or altered mental status.
3. Client has a history of falls and orthostatic hypotension per client's partner – A significant risk factor for future falls.
4. Client uses a walker – Indicates mobility impairment.
5. Client ordered new glasses following an eye exam last week but has not received them yet – Vision impairment increases fall risk.
6. Blood pressure: Lying: 130/90 mm Hg, Sitting: 128/88 mm Hg, Standing: 98/60 mm Hg – Orthostatic hypotension (drop in BP upon standing) can cause dizziness and falls.

1. Oxygen Saturation (90%) – This is a drop from the initial 95% and indicates potential hypoxia. The increased respiratory rate and depth may be compensatory mechanisms.
2. Behavioral Findings ("I feel like something is wrong.") – Clients experiencing early signs of deterioration often report a sense of unease. This, combined with agitation, could indicate worsening hypovolemia or hypoxia.

The client's low hemoglobin (8.3 g/dL) and hematocrit (32%) suggest significant blood loss during surgery, which could contribute to hypoxia and hemodynamic instability. Immediate follow-up is needed to assess for potential ongoing bleeding, oxygenation issues, or early signs of shock.

The client is at risk for developing constipation due to opioid use.

Rationale:

• Opioid Use → Constipation: Oxycodone, like other opioids, slows gastrointestinal motility, leading to constipation. This is a common postoperative concern, especially in clients with reduced mobility after a hip arthroplasty.

  • Confusion – No signs of mental status changes or factors like electrolyte imbalances.
  • Pressure Injuries – While immobility increases risk, this is not directly related to the provided findings.
  • Hypoglycemia – Blood glucose is normal, and there’s no IV dextrose mentioned.
  • Dysrhythmias – Potassium and sodium levels are within normal limits, reducing electrolyte-related cardiac risks.

The client is most at risk of developing atelectasis and paralytic ileus.

Rationale:

1. Atelectasis – The client has shallow breathing and received IV morphine, which can suppress respiratory effort. Postoperative clients, especially those with abdominal surgery, are at higher risk for atelectasis due to pain-related splinting and immobility.

2. Paralytic Ileus – The client has hypoactive bowel sounds at both assessments, indicating delayed return of bowel function postoperatively. This is common after abdominal surgery, especially with opioid use, and can lead to paralytic ileus.

• Urinary tract infection (UTI) – The client has voided 350 mL of clear yellow urine, indicating normal urinary function post-catheter removal.
• Delayed wound healing – There is no sign of wound complications (dressing remains dry and intact).
• Deep vein thrombosis (DVT) – No signs of unilateral swelling, redness, or pain, and the client is wearing sequential compression devices to prevent DVT.